Waivers

Tera Steagall Personal Training Program Policies and Liability Release First Name:

Last name:

Address

City:

State/Zip:

Email:

Home #:

Cell#:

DOB:

Age:

Gender

Emergency contact:

Contact#:

Welcome! I am delighted that you chose to train with me as a part of your commitment to health and fitness. I’m here to provide you with the necessary information and motivation to help you reach and maintain your personal fitness goals. The following information will provide you with important program policies. Before getting started, please read and sign this form so that I can be sure that you have been provided with and understand this information. Tera's Personal Training Policies:

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All forms including Exercise History and Attitude Questionnaire, Physical Activity Profile, Lifestyle Information Form, Health History Form, PAR-Q and Policies and Liability Release must be filled out and signed prior to the start of the first personal training session/orientation.

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Rates: Vary between individuals.

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Training sessions will begin promptly at the time specified by client and trainer. Payment will be made prior to session. Please be on time in order to make full use of the training session. Each training session is 50 minutes to one hour in length unless otherwise agreed upon between the client and the trainer.

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Cancellations: In order to cancel or reschedule an appointment, you must contact me at least 24 hours in advance of the scheduled appointment or you will be charged for that session. (NOTE: any exception to this policy will be made purely at the discretion of the trainer.) Similarly, if I do not contact you at least 24 hours in advance to cancel or reschedule an appointment, you will receive one complimentary session.

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All clients are encouraged to be prompt. If the client is 10 minutes late or more for a session this time will be deducted from it. If possible, the trainer will attempt to complete the entire session if his schedule allows it. If the trainer arrives late, the amount of time will be added for an extended session. Please be advised that after waiting 15 minutes for a scheduled client, the session is subject to cancellation and clients will be charged for a full session.

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I do not offer refunds or credits, so please be sure that my services will match your needs before committing through payment. If you find that your needs change once you have begun this program, please let me know; I am eager to find a way to accommodate your training needs

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Injury: You are fully responsible for any injury you incur before, during, or after workouts.

The trainer will not be held accountable in any manner, legal or otherwise. Any injury incurred before, during, or after workout sessions is solely the responsibility of the client. Focusing during your workout and following directions will help prevent any injury. It’s the client’s responsibility to communicate any symptoms or discomfort during the session.

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No verbal agreement can alter or change the conditions of this agreement in any part. Release, Covenant Not to Sue, and Waiver

I, __________________________________, do hereby consent to participate in a personal training program that will include weight training and/or cardiovascular exercise. I have been informed and understand that physical exercise has been associated with certain risks, including but not limited to musculoskeletal injury, spinal injuries, abnormal blood pressure responses, and, in rare instances, heart attack or death. Every effort will be made to minimize these risks. Any information that is obtained regarding my fitness level and my progress will be treated as privileged and confidential and will not be released or revealed to any person other than my physician without my expressed written consent. I have read and understand the foregoing consent to participation in said program. I am aware that I may discontinue participation in the program at any time that I see fit to do so. If at any time I have questions concerning the content, policies, or procedures regarding the personal training program I will discuss these questions with my trainer immediately. In addition, I agree to the following: a) Assume all risk of injury and all risk of damage to or loss of property arising out of my participation in this program. b) Release, discharge, and waive any and all responsibility from Diego Schmunis from and against any liability of injury, including death, and for damage to or loss of property which may be suffered by the undersigned arising out of, or in any way connected with the participation in this program. c) Indemnify and hold Tera Steagall harmless from and against all liability, claims, demands, actions, loss, and damage arising out of my participation in said personal training program. By signing this document, the undersigned hereby acknowledges that he/she has read the above carefully before signing, and agrees to comply with all the above. Signature: ____________________________ Print Name:__________________________ Date:

The Physical Readiness Questionnaire – PAR-Q Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor first.

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

YES

NO

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs for your blood pressure or heart condition? 7. Do you know of any other reason why you should not do physical activity? If you answered YES to one or more questions:

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Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR- Q and which questions you answered YES.

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You may be able to do any activity you want –as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.

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Find out which community programs are safe and helpful to you.

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If you answered NO honestly to all PAR-Q question, you can be reasonably sure that you can: Start becoming much more physically active –begin slowly and build up gradually. This is the safest and easiest way to go.

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Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. DELAY BECOMING MUCH MORE ACTIVE:

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If you are not feeling well because of a temporary illness such as a cold or a fever- wait until you feel better Or

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If you are or may be pregnant – talk to your doctor before you start becoming more active.

PLEASE NOTE: If your health changes so that you have to answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical

activity plan. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. Name:

Signature:

Date:

Health History Form

Are you taking any medication or drugs? If so, please list medication, dose and reason:

Does your physician know you are participating in this exercise program?

Describe any physical activity you do somewhat regularly:

Do you now, or have you had in the past:

YES

NO

1. History of heart problems, chest pain or stroke 2. High or low blood pressure 3. Any chronic illness or condition 4. Difficulty with physical exercise 5. Advice from physician not to exercise 6. Recent surgery (last 12 months) 7. Pregnancy (now or within last 3 months) 8. History of breathing or lung problems 9. Muscle, joint or back disorder 10. Previous injuries not fully healed 11. Diabetes or thyroid conditions 12. Cigarette smoking habit 13. Obesity (more than 20% over ideal body weight) 14. HIV 15. History of heart problems in immediate family 16. Hernia, or any condition that my be aggravated by lifting weights 17. OTHER (provide description under comments) Please explain any “YES” on the comments section below.

Comments:

Lifestyle Information Form

In the past year, how often have you been engaged in physical activity? Regularly (3 to 4 times/week): Semi regular (1 to 2 times/week): Sporadic (1 to 2 times/month): None: What type of physical activity do you consider “fun”?

What are your personal barriers to exercise?

What physical activity have you been successful with in the past?

How do you think your weight affects your daily activities?

Support Do you feel any family; friends or co-workers have negative feelings toward your efforts at physical activity? Is your significant other or close friend involved in any regular physical activity?

Occupation/leisure What is your present occupation? Does your occupation require much activity?

What are your usual leisure activities?

Stressors What types of things make you feel stressed? How do you deal with your stress normally?

Dietary patterns How many meals and/or snacks do you have per day?

What would you estimate your caloric intake to be per day?

Do you fell you eat healthy “most of the time””

How much water do you drink a day?

Expectations Specifically describe what you would like to accomplish through your fitness program during the next: 1 month: 6 months: 1 year: Exercise History and Attitude Questionnaire 1.

Please rate your exercise level on a scale of 1 to 5 (5 indicating very high) Years old: 15-20 21-30 31-40 41-50 60+

51-60

2.

Do you have any negative feeling toward, or have you had any bad experiences with physical activity programs? YES:  NO: - If yes, please explain:

3.

Do you have any negative feelings toward, or have you had any bad experiences with fitness testing and evaluation? YES:  NO: - If yes, please explain:

4.

Rate yourself on a scale 1 to 5 (5 indicating very high). Circle the number that best applies. Characterize your present athletic ability: 1 2 3 4 5 When you exercise, how important is competition? 1 2 3 4 5 Characterize your present muscular capacity: 1 2 3 4 5 Characterize your present flexibility capacity: 1 2 3 4 5 Characterize your present aerobic capacity: 1 2 3 4 5

5.

Do you start exercise programs but then find yourself unable to stick with them? YES  NO - If yes, please explain:

6.

How much time are you willing to devote to an exercise program? ________ minutes/day ________ days/week

7.

Are you currently involved in regular endurance (cardiovascular) exercise? YES:  NO:



- If yes, please explain type of exercise: ________ minutes/day ________ days/week Rate your perception of the exertion of your exercise program (5 indicating very high) 1 2 3 4 5 8.

How long have you been exercising regularly? ________ months ________ years

9.

What other exercises, sport or recreational activities have you participated in?

In the past 6 months?

In the past 2 years?

10.

Can you exercise during your workday? YES:  NO:

11.

Would an exercise program interfere with your job? YES:  NO:

12.

Would an exercise program benefit your job? YES:  NO: - If yes, how:

13.

What type of exercise interest you? walking: cycling:  stationary biking: tennis: 

14.



jogging: dance exercise: rowing/kayaking: other aerobics:

Rank your goals in undertaking exercise:

   

swimming: strength training: stretching:

What do you want exercise to do for you? Use the following scale to rate each goal separately. Circle the appropriate number 1-Not at all

2-Somewhat

3- Important

4- Extremely

Improve cardiovascular fitness

1

2

3

4

Body-fat weight loss

1

2

3

4

Reshape or tone my body

1

2

3

4

Improve performance for specific sport

1

2

3

4

Improve moods and ability to cope with stress

1

2

3

4

Improve flexibility

1

2

3

4

Increase strength

1

2

3

4

Increase stamina and energy level

1

2

3

4

Feel better

1

2

3

4

Enjoyment

1

2

3

4

Other

1

2

3

4

15.

By how much would you like to change your current weight? (+) lbs: (-) lbs:

16.

How quick? Physical Activity Profile

Please answer the following questions about your work and non-work related physical activities. How would you rate the amount of physical activity you perform while at work? little:

very little:

moderate:

active: 

very active:

How would you rate the amount of physical activity you perform during your leisure time? little:

very little:

moderate:

active: 

Are you presently performing any standard physical fitness program? YES:

 NO:

If YES, what kind?

very active:

How physically fit do you feel at the present time? little:

very little:

moderate:

active: 

Do you have any exercise equipment or device at home? YES:

 NO:

If YES, what kind?

Personal Statement Of Purpose: I am entering this evaluation program and starting to exercise because I want to:

very active: